Tennis elbow

Tennis elbow

Published by Bupa's health information team, June 2007.
This factsheet is for people who have tennis elbow, or who would like information about it.
Tennis elbow is the common name for a painful condition affecting the outside part of the elbow. Tennis elbow is most common in people aged between 35 and 55. Depending on the severity, it can take from two months to two years to heal fully.

What is tennis elbow?

The medical term for tennis elbow is lateral epicondylitis because it affects the outside of the elbow bone called the lateral epicondyle. The cause of the problem is damage to a tendon that joins the extensor muscles of the forearm to the upper arm bone (humerus). This tendon is called the common extensor tendon (see diagram).


The elbow joint

Tendon damage can occur after a single incident, such as lifting something very heavy, causing a tear in the tendon. But the most common cause is repeated overuse of the arm.

This overuse causes tiny tears (called microtears) in the tendon. You will make this worse if you continue doing the activity that triggered the pain and if you don't rest your arm. If you continue aggravating the injury you may get a more serious tear or even rupture your tendon.
Causes and risk factors

Playing tennis three times in a week when you haven't played for some time is the sort of overuse that could cause tennis elbow. But most people who develop tennis elbow have not been playing tennis. A range of different activities that involve repeated hand, wrist and forearm movements can be the cause. These include:

* using a computer mouse (especially if you have poor arm and neck posture)
* using a computer keyboard
* using vibrating equipment, such as strimmers
* using scissors or shears
* gardening
* manual occupations that involve repetitive twisting and lifting of the wrist - including plumbing, bricklaying and use of a screwdriver
* playing musical instruments such as the violin

Symptoms

The main symptom is pain and tenderness on the outside of the elbow and sometimes in the muscles on top of the forearm. Tennis elbow usually affects the arm of your dominant hand (right arm if you are right-handed) because this is the arm you use the most.

The symptoms usually develop gradually. The pain may go away after a day or so. But if you repeat the activity that triggered the pain, it may get worse as you will increase the damage to your tendon. The pain may become constant and even interrupt your sleep.

Other symptoms include:

* your affected arm feels stiff in the morning and painful when you turn door handles or shake hands
* your affected arm feels weak and heavy
* pain or stiffness in other parts of your affected arm, or your shoulder or neck, as your body tries to compensate for the weakness in your elbow

When to see your doctor

If you have severe elbow pain, can't move the joint or have any loss of feeling, you should seek medical treatment urgently.

Most people with mild symptoms of tennis elbow can try home treatments (see Home treatment). But if your symptoms don't improve after a couple of weeks, you should see your GP or physiotherapist.
Diagnosis

Your GP can usually diagnose tennis elbow from examining your arm and hearing about how your symptoms developed. An X-ray is rarely needed, but your GP may recommend having one to rule out other conditions, such as arthritis, that can cause elbow pain.

For severe tennis elbow that has failed to heal with normal treatment, your GP might suggest an MRI scan or ultrasound. These give images of the soft tissues, including muscles and tendons, inside your arm.
Treatment

To make a full recovery, you need to change the way you use your arm so that your tendon is rested and has time to heal. Exactly how you do this depends on how you came to have tennis elbow and how severe it is.

Treatment for tennis elbow includes the following.

* Reduce inflammation and pain. Your GP may prescribe medicines to reduce inflammation. Your physiotherapist may try various techniques to reduce the pain. These may include acupuncture, ultrasound, deep tissue massage and correcting posture. For tennis elbow that has failed to heal with normal treatment, a doctor may suggest a steroid injection, which can help relieve pain and inflammation.
* Activity modification. Your physiotherapist can advise you on how to improve your posture, or improve your technique at sports and other activities to help prevent further injuries. This may involve having a workstation assessment if your tennis elbow is due to your work.
* Rehabilitation. This involves strengthening exercises, such as a structured loading programme of the tendon as well as stretching. Your physiotherapist will be able to advise you on this.
* Arm brace or tape. This can alter where the tendon works from and allow the inflammation to settle.

Home treatment

You can treat your symptoms yourself if you have mild tennis elbow. The most important part of the treatment is to rest your injured tendon by stopping or changing the activity that is causing the problem. To relieve your symptoms, you can do the following.

* Apply an ice pack - to reduce the pain and swelling. Immerse your arm in ice for 10 minutes or use an ice pack (a bag of frozen peas will do) for 10 to 30 minutes. Don't apply the ice directly to your skin because it can cause cold injury - place a cloth between the ice your skin. Repeat every couple of hours as needed for the next 48 hours, allowing your arm to warm up between ice sessions.
* Take anti-inflammatory medicine - such as ibuprofen, according to the directions on the packet, up to the maximum daily dose. Ibuprofen is not suitable for people who have stomach ulcers, or for some people with asthma. If in doubt, ask your pharmacist or doctor for advice. Ibuprofen belongs to a group of drugs called non-steroidal anti-inflammatory drugs (NSAIDs). Always read the patient information leaflet that comes with your medicine. Other types of NSAIDs may be more appropriate for some people.
* Wear an arm brace - this is a form of strapping that you can wear around your forearm and elbow to help restrict the movement of your tendon. You can buy arm braces from some physiotherapists, larger pharmacies and sports shops. Your physiotherapist will be able to advise you on how to use it.
* Modify technique - when doing a manual task you can't avoid, use a tool with a smaller grip. If available, you should contact your employer's occupational health advisers. They can give advice on how to change your daily activity at work to allow your arm to heal.

Other treatments

Your GP can prescribe stronger types or doses of NSAIDs than those you can buy from your pharmacist. He or she may refer you to a sports medicine doctor, a rheumatologist or a physiotherapist.

Surgery may be an option if the tendon is severely damaged, or if there has been no improvement after many months of rest and rehabilitation. However, very few people need surgery.
Prevention

Tennis elbow is an overuse injury, so it can be prevented. A few sensible precautions include:

* warm up for activity with five minutes of gentle movements - this allows time for your muscles to adjust to the extra stresses and strains
* try not to do the same activity for long periods of time - take regular breaks
* seek advice early from your doctor or physiotherapist if you notice a problem

To prevent an old tennis elbow injury from coming back, you should:

* cut down on the type of activity causing the problem
* give yourself proper rest between sessions
* don't play sport if your arm is painful